DI 11052.015 Processing End-Stage Renal Disease Medicare Claims Involving Insured Status Based on Medicare Qualified Government Employment
A. Background on insured status
Under section 278 of Public Law 97-248 (Tax Equity and Fiscal Responsibility Act of 1982), Federal employees are subject to the hospital insurance (HI) Medicare portion of the Federal Insurance Contributions Act (FICA) tax beginning January 1, 1983. In return, such employees earn quarters of coverage (QC) for Medicare only entitlement purposes from government employment for wages paid after December 31, 1982. In addition, under a transitional provision in the law, Federal employees in pay status during January 1983 may receive deemed QCs for their Federal service prior to 1983. The first possible month of HI entitlement based on government employment quarters of coverage (GEQC) is January 1983. However, the qualifying period may begin prior to January 1983.
B. ESRD case processing
If the claimant meets insured status without considering GEQCs, process the claim under regular ESRD procedures. If we use government employment to determine if insured status is met, process the claim as in an initial claim with the following additional considerations:
Complete Form SSA-892, End-Stage Renal Disease (ESRD) Medicare Determination as outlined in HI 00801.308. If the claimant is the spouse or dependent child of the insured government employee, indicate the government employee's Social Security number (SSN) in item 4 and his or her name in item 6. We establish Medicare entitlement on the government employee's SSN followed by the appropriate government Medicare Beneficiary Identification Codes (BIC). Show “GEQC” in item 39 (this entry alerts the adjudicators to the SSN entry in item 4). See SM 00550.010, Beneficiary Identification Codes (BIC) and Payment Identification Codes (PIC).
EXAMPLE: If a child is filing for ESRD Medicare using the father’s MQGE insured status, we do not establish the child as a BIC T on his or her own SSN. Instead, we establish the child as a BIC TC1 on the father’s SSN. The field office (FO) will still take the ESRD claim on the claimant’s SSN and prepare an A101.
When adjudicating ESRD Medicare awards using GEQCs for insured status, use the government worker’s SSN and process these cases via Earnings Computation (EC). On the MREQ screen (first screen of the earnings computation request), indicate “Y” to process as MQGE. Preparation of an A101 is necessary only when you base insured status on a spouse’s or parent’s GEQCs.
If the claimant receives a pension from the Office of Personnel Management (OPM), complete the Health Insurance-Supp Medical Insurance (HICL) screen in the clearance screen path in MCS to establish SMI premium deduction from the civil service pension. If OPM withholds premiums from the spouse’s civil service annuity, show a STAT of “S”; otherwise leave this field blank.
DI 11035.010, FO Processing of Medicare for Qualified Government Employment (MQGE) Disability Claims